The Village Referral to Shelter Services

The Village Referral to Shelter Services
If you would like someone to be considered for our services, please follow our referral and approval process. To be eligible for Village services, referrals must meet at least one of the following criteria: being chronically homeless, fleeing domestic violence, being a veteran, having a documented disability, or being over the age of 55.

We recognize that the need for services is high and resources are limited. Please note that we cannot accept out-of-county or out-of-state residents, or drop-offs from other agencies, without prior approval.

To submit a referral, please complete the appropriate form. Referrals will be evaluated based on program availability. While waiting for space in other programs, any Douglas County resident may access our Night-by-Night Program (7 pm–8 am), provided they are able to meet the LCS Expectations.

Please be aware that we are unable to serve individuals who cannot meet their own basic care needs, including the ability to perform personal hygiene, toilet unassisted, eat unassisted, dress and undress independently, and ambulate and navigate the building and surrounding area without assistance.

Thank you for your understanding and cooperation.
1. Your Name

First NameLast Name
Email
example@example.com
Agency and Title
2. Referral Name

First NameLast Name
Contact Information

Email (example@example.com)Phone Number
Date of Birth

MonthDayYear
Must be 18 or older.
Marital Status

SingleMarried (applying with spouse)Married (applying separately)
Spouse Name if Applicable (enter NA in both fields if not)

First NameLast Name
3. Does the individual have a criminal history? Particularly violent criminal charges? When? Please explain:
4. Is the individual a Douglas County resident?

YesNoNot Sure
5. If they are not a Douglas County resident what connections supports or resources do they have available to them in Douglas County? (enter NA if not applicable)
6. Is the individual currently unsheltered or staying in a place not intended for human habitation?

YesNoNot Sure
7. Has the individual been entered into Clarity?

YesNoNot Sure
8. Does the individual have a completed CES Assessment?

YesNoNot Sure
If Yes, what was their score and when was the assessment conducted? (Please put "N/A" if not applicable of "Not Sure" if unknown)
9. Does the individual meet the definition of chronic homelessness? (Chronic homelessness refers to individuals who have been homeless for at least one year — or on multiple occasions over a three-year period — while living with a disabling condition such as a serious mental illness, substance use disorder, or physical disability.)

YesNoNot Sure
10. Does the individual meet any of the following criteria?

VeteranSenior (55 or over)Documented DisabilityFleeing or Survivor of Domestic ViolenceOther
11. Please provide details on the selected criteria above and/or define other if selected:
12. Village guests are required to participate in wrap-around services, including case management. What agencies is the referral working with?

Bert Nash Community Mental Health CenterCity Team (Lawrence Homeless Solutions)DCCCADCSO ReentryFamily PromiseHaskell Indian Health CenterHeartland Community Health CenterLawrence Community ShelterLawrence Humane SocietyRed CrossRADACVeterans AffairsThe WillowWork for SuccessOther
Please define "Other" if applicable and add case manager's name and contact information:
13. What agencies is the referral interested in working with? Referrals are encourage to start services while on the wait list.

Bert Nash Community Mental Health CenterCity Team (Lawrence Homeless Solutions)DCCCADCSO ReentryFamily PromiseHaskell Indian Health CenterHeartland Community Health CenterLawrence Community ShelterLawrence Humane SocietyRed CrossRADACVeterans AffairsThe WillowWork for SuccessOther
Please define "Other" of applicable. Enter "NA" if not.
14. Does the referral have a pet?

YesNoDocumented Certified Service Animal
The Village does not allow animals on site. Referrals are required to make arrangements for the pet to be fostered or boarded before entering the Village. If you need assistance, please contact Lawrence Humane Society Pet Resource Center for more information as soon as possible.
15. Is there anything else you would like for us to know or consider?
Please also fill out and upload the linked forms in the upload section below:

3rd Party Homeless Verification Referral - LINK

Community Partner ROI - LINK
File Upload

Cancelof
Thank you for your referral.
Should be Empty: